FEATURE: PERSPECTIVE

Opportunities and Challenges: Residents’ Perspectiveson the Next Accreditation System in Psychiatry

Alik S. Widge & Heather E. Schultz

Received: 30 November 2013 /Accepted: 5 March 2014 /Published online: 25 March 2014# Academic Psychiatry 2014

Keywords Accreditation . Graduatemedical education .

Internship and residency

The unfolding of the Accreditation Council on GraduateMedical Education (ACGME)’s Next Accreditation System(NAS) and its corresponding Milestones introduce new dataelements into resident evaluation. In theory, these new regu-lations should be welcomed and freeing for programs andtrainees alike. The switch to a self-study model will reducesite visits and may relieve the associated cycles of panic.Standardized evaluations across programs should allow us tomore directly compare graduates of different residencies. Thegrand vision is that these comparative data will act in avirtuous cycle, encouraging programs and individual traineesto try harder and innovate more [1]. NAS is intended as a steptowards the utopia of “value-based health care” that wastaught to us in medical school, but of which we have seenfar too little on the wards [2].

That perspective has much to recommend it. First, althoughthe Milestones were developed by committee and containmuch that is subjective, they are grounded in both evidenceand the collective experience of multiple respected educators.Residents can take comfort that we will be measured by ayardstick that is fair, rigorous, and well-aligned to the neededskill-set of a 21st century psychiatrist. This is doubly truegiven that the Psychiatry Milestones come with suggestedassessment tools and anchors. No longer will an entire year

be summarized by a stack of Likert scales filled with averagescores and empty comment boxes. Second, a key value of theMilestones is identification of our individual areas of distinc-tion and deficit. We and our faculty preceptors will knowwhere we need help, and we can seek out mentors to remedyour weaknesses. Where we are exceptional, we will havestandardized data to prove it. Those data could be the doorto greater autonomy at an earlier stage, opportunities forteaching and scholarship, and leadership roles earlier thanthe chief year. All those things happen now, as strengths areorganically recognized by faculty, but the Milestones couldeasily expedite the process. They will also galvanize newteaching, as neuroscience, system-based practice, and formalself-improvement take on the same stature in education thatthey are rapidly gaining in psychiatric practice. As notedelsewhere in this issue, the Milestones codify expectations incompetencies that have long been neglected, but that will becritical in coming decades.

Beyond the immediate horizon, Milestones might be thebridge to a portfolio-model residency. The ongoing crisis inFederal Graduate Medical Education (GME) funding, hasfueled a growing call for shorter and more flexible training[3]. Although the current framework is not explicitly designedto support this, it is easy to imagine a future in which rapidprogression through Milestones qualifies a resident for earlygraduation, perhaps even earlier than is achievable under thecurrent “fast tracking” system. Although there would be muchto resolve in terms of funding, such a scenario could benefitboth trainees (by bringing us more quickly to attending sala-ries) and payors (by maximally leveraging GME dollars).

NAS’ designers hope that all programs are (or want to be)above average, and thus, their residents also will be. Unfortu-nately, all of us, from the newest intern to the most seniorfaculty, know this to be untrue. Problem residents have existedas long as there have been residencies, and the objectivity ofthe Milestones will make their deficiencies blatant and un-

A. S. Widge (*)Massachusetts General Hospital, Charlestown, MA, USAe-mail: awidge@partners.org

H. E. SchultzUniversity of Michigan Health System, Ann Arbor, MI, USA

Acad Psychiatry (2014) 38:303–304DOI 10.1007/s40596-014-0094-y

ignorable. For every trainee who excels under the Milestones,another will demonstrate clearly unsatisfactory progress. Willthat resident graduate, or must his/her training be extended?How will a stipend be guaranteed during that extended time?How can early fellowship matches operate if there is nocertainty of Milestone achievement before fellowship matric-ulation? We have no answers—and neither, it seems, doesanyone else. The only certainties are that some of our col-leagues will see their career plans deviate sharply once NASgoes into effect and that next years’ chief residents will faceexceptionally difficult decisions.

Neither is every psychiatric training program truly aboveaverage. Both of us have served as resident representatives toACGME’s Psychiatry Residency Review Committee, and wehave seen site visits reveal problems that no other instrumentuncovers. Under NAS, the only site visits will be self studies,conducted decennially [1]. How will we find the places wherebasic supervisory responsibilities are being neglected? Whereresident or patient safety takes a back seat to financial con-cerns? The ACGME Resident Survey cannot carry that load;the survey is feared and mis-answered by program directorsand trainees alike [4–6]. In theory, trainees in particularlyegregious programs will not progress at the expected rate,and ACGME data collection will flag those outliers. In prac-tice, every instrument is subject to user error, and there is noguarantee of accurate data collection. TheMilestones and theirrating forms are clear, but they depend on the motivation ofboth teachers and learners. It would be easy enough for anevaluator to simply score every resident at his/her level oftraining, or to leave key items blank due to inadequate obser-vation. Perhaps national-level statistics can identify such“faulty sensors” and troubled programs; only the experienceof the next few years will tell.

Finally, we wonder: what about the many aspects of psy-chiatry that cannot be quantified? In psychiatry, more than anyother specialty, the “art” of medicine persists. It can be found,for instance, in the integration of psychopharmacology withtherapy while understanding the dual backdrop of neurosci-ence and psychodynamics. Becoming a psychiatrist is morethan linear progression along a path of skills and knowledge; itis assimilation into a professional community, and it ofteninvolves developing the first glimmers of personal insightand wisdom. Boundary crossings can be observed and ratedby supervisors; it is much harder to rate whether a residenttruly understands countertransference or is developing a senseof professional identity. These topics are covered in the Mile-stones, and it is essential that they be considered, but there isrichness that cannot be captured on even an expertly craftedform. Quantitative semiannual Milestone data will meet

ACGME mandates, and may well improve psychiatric train-ing, but when promotion or hiring decisions need to be made,data will be no substitute for an open and honest discussionwith a resident’s peers or supervisors.

What we can say for certain is that the NAS will generatevoluminous and detailed data. For now, those data areprotected. ACGME is considered a peer review organization,and it would be profoundly difficult to compel release ofMilestone assessments for any public or legal purpose. TheAmerican Board of Psychiatry and Neurology has stated noplans to use Milestone data, and will continue to rely on theprogram director’s judgment that a resident is prepared tograduate and sit for the board exam. On the other hand,10 years ago, the NAS itself would have been infeasible. Ifprivate or public payors do agree to greater financial supportof GME, there will be strings attached [3, 7]. That demand foraccountability is a key motivator behind NAS [1].Once creat-ed, data are not easily kept bottled, and we may be at thebeginning of a much greater experiment in “physician quan-tification”. We remain optimistic that the Milestones will be aforce for positive change in our profession, but that optimismis tempered with caution.

Conflicts of interest Both authors have received expense reimburse-ment from ACGME for participation in Residency Review Committeeactivities and associated meetings. We otherwise declare no financial orother conflicts of interest related to this work.

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